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Allen A, Francisco MA, Jatis J, Turner Y, Nordgren R, Rubin D, Huisingh-Scheetz M, Bryan DS, Donington J, Ferguson MK, Gleason LJ, Madariaga ML. Implementing a Frailty-Specific Postoperative Order Set to Improve Postoperative Outcomes in Frail Adults After Elective Thoracic Surgery. J Nurs Care Qual 2024; 39:361-368. [PMID: 38936412 DOI: 10.1097/ncq.0000000000000784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
BACKGROUND Frailty is independently associated with adverse patient outcomes after surgery. The current standards of postoperative care rarely consider frailty status. LOCAL PROBLEM There was no standardized protocol to optimize specialized postoperative care for frail patients at an academic medical center. METHODS A quasi-experimental pre-/postimplementation study design, using the Reach, Effectiveness, Adoption, Implementation, Maintenance implementation framework, was utilized. INTERVENTIONS A frailty-specific postoperative order set (FPOS) was developed, including tailored nursing care, activity levels, and nutritional goals. RESULTS There were significant improvements in nurse's self-reported familiarity with frailty ( P = .003) and FPOS awareness ( P < .001). The number of orders for delirium prevention, elimination, nutrition, sleep promotion, and sensory support increased ( P < .001). CONCLUSIONS Implementing an FPOS showed improvements in nurse frailty knowledge, awareness, and order set utilization.
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Affiliation(s)
- Amani Allen
- Author Affiliations: The University of Chicago Pritzker School of Medicine (Dr Allen), Department of Public Health Sciences (Dr Nordgren), Department of Anesthesia and Critical Care (Dr Rubin), Section of Geriatrics and Palliative Medicine, Department of Medicine (Drs Huisingh-Scheetz and Gleason), Section of Thoracic Surgery, Department of Surgery (Drs Bryan, Donington, Ferguson, and Madariaga), University of Chicago, Chicago, Illinois; and Department of Nursing Research and Evidence Based Practice (Mss Francisco, Jatis, and Turner), University of Chicago Medical Center, Chicago, Illinois
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Ng ZX, Handa P, Zheng H, Chen MZ, Soon YY, Blinman P, Stockler M, Ho F. Health-related quality of life with comprehensive geriatric assessment guided care versus usual care in older adults with cancer: A systematic review and meta-analysis of randomized trials. Crit Rev Oncol Hematol 2024; 201:104442. [PMID: 39002788 DOI: 10.1016/j.critrevonc.2024.104442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/29/2024] [Accepted: 07/06/2024] [Indexed: 07/15/2024] Open
Abstract
BACKGROUND To evaluate if comprehensive geriatric assessment (CGA)-guided care improves health-related quality of life (HRQL) in older adults with cancer compared to usual care. METHODS Relevant randomized controlled trials (RCTs) were identified through biomedical databases. Meta-analyses using DerSimonian-Laird model summarized the difference in the mean change of HRQL scores from baseline across various time points, with evidence certainty assessed by the GRADE tool. Logistic regression via generalized estimating equations analyzed predictors of HRQL improvement. RESULTS Potential improvement in the global HRQL score by CGA-guided care at 3 months (Cohen's d 0.27, 95 % CI -0.03-0.58, moderate certainty), could not be excluded. Larger RCTs or those mandating CGA before initiating anti-cancer treatment were predictors of improved HRQL. CONCLUSION The effects of CGA-guided care on HRQL were variable. Larger RCTs and those mandating pre-treatment CGA tended to report improved HRQL.
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Affiliation(s)
- Zhi Xuan Ng
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore
| | - Pooja Handa
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore
| | - Huili Zheng
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - Matthew Zhixuan Chen
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.
| | - Prunella Blinman
- Department of Medical Oncology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Martin Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia; Department of Medical Oncology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Francis Ho
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Denkinger M, Wirth R, van den Heuvel D, Leinert C, Gosch M. [Care models for older people based on a case study-Geriatrics as an active discipline]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:880-889. [PMID: 39120708 DOI: 10.1007/s00108-024-01758-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 08/10/2024]
Abstract
Geriatrics can enable and monitor a holistic care of older people through a comprehensive geriatric assessment in a structured way. Therefore, it must be integrated much more closely with preventive, rehabilitative and acute care units. Geriatrics are not seen in any aspects as a replacement for general practitioners or in-hospital structures but much more as a supplement to them. With its function-oriented concept, geriatrics can best coordinate the demographically necessary triage between prevention, acute treatment, rehabilitation and palliative care, thus avoiding undertreatment and overtreatment. This can only succeed in collaboration with general practitioners and specialist colleagues. The article categorizes geriatric care structures, such as preventive home visits, acute complex medical treatment, delirium prevention, outpatient and inpatient rehabilitation services based on a case example and makes proposals for structural changes that urgently need to be considered in the current healthcare reform, such as outpatient geriatric centers (AGZ).
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Affiliation(s)
- Michael Denkinger
- Geriatrisches Zentrum an der AGAPLESION Bethesda Klinik Ulm, Zollernring 26, 89073, Ulm, Deutschland.
- Institut für Geriatrische Forschung, Universitätsklinikum Ulm, Ulm, Deutschland.
| | - Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne - Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland
| | | | - Christoph Leinert
- Geriatrisches Zentrum an der AGAPLESION Bethesda Klinik Ulm, Zollernring 26, 89073, Ulm, Deutschland
- Institut für Geriatrische Forschung, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Markus Gosch
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Nürnberg, Deutschland
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Chen L, Zong W, Luo M, Yu H. The impact of comprehensive geriatric assessment on postoperative outcomes in elderly surgery: A systematic review and meta-analysis. PLoS One 2024; 19:e0306308. [PMID: 39197016 PMCID: PMC11356442 DOI: 10.1371/journal.pone.0306308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/15/2024] [Indexed: 08/30/2024] Open
Abstract
INTRODUCTION The elderly population experiences more postoperative complications. A comprehensive geriatric assessment, which is multidimensional and coordinated, could help reduce these unfavorable outcomes. However, its effectiveness is still uncertain. METHODS We searched multiple online databases, including Medline, PubMed, Web of Science, Cochrane Library, Embase, CINAL, ProQuest, and Wiley, for relevant literature from their inception to October 2023. We included randomized trials of individuals aged 65 and older undergoing surgery. These trials compared comprehensive geriatric assessment with usual surgical care and reported on postoperative outcomes. Two researchers independently screened the literature, extracted data, and assessed the certainty of evidence from the identified articles. We conducted a meta-analysis using RevMan 5.3 to calculate the Odds Ratio (OR) and Mean Difference (MD) of the pooled data. RESULTS The study included 1325 individuals from seven randomized trials. Comprehensive geriatric assessment reduced the rate of postoperative delirium (28.5% vs. 37.0%; OR: 0.63; CI: 0.47-0.85; I2: 54%; P = 0.003) based on pooled data. However, it did not significantly improve other parameters such as length of stay (MD: -0.36; 95% CI: -0.376, 3.05; I2: 96%; P = 0.84), readmission rate (18.6% vs. 15.4%; OR: 1.26; CI: 0.86-1.84; I2: 0%; P = 0.24), and ADL function (MD: -0.24; 95% CI: -1.27, 0.19; I2: 0%; P = 0.64). CONCLUSIONS Apart from reducing delirium, it is still unclear whether comprehensive geriatric assessment improves other postoperative outcomes. More evidence from higher-quality randomized trials is needed.
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Affiliation(s)
- Lin Chen
- Anesthesia and Surgery Department, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
| | - Wei Zong
- Department of Critical Care Medicine, First Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Manyue Luo
- Endocrinology and Metabolism Department, Changsha People’s Hospital, Changsha, Hunan, China
| | - Huiqin Yu
- Anesthesia and Surgery Department, Chengdu Second People’s Hospital, Chengdu, Sichuan, China
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Loh KP, Liposits G, Arora SP, Neuendorff NR, Gomes F, Krok-Schoen JL, Amaral T, Mariamidze E, Biganzoli L, Brain E, Baldini C, Battisti NML, Frélaut M, Kanesvaran R, Mislang ARA, Papamichael D, Steer C, Rostoft S. Adequate assessment yields appropriate care-the role of geriatric assessment and management in older adults with cancer: a position paper from the ESMO/SIOG Cancer in the Elderly Working Group. ESMO Open 2024; 9:103657. [PMID: 39232585 PMCID: PMC11410714 DOI: 10.1016/j.esmoop.2024.103657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/29/2024] [Accepted: 07/01/2024] [Indexed: 09/06/2024] Open
Abstract
With the aging population, older adults constitute a growing proportion of the new cancer cases. Given the heterogeneous health status among older adults and their susceptibility to aging-related vulnerabilities, understanding their diversity and its implications becomes increasingly crucial for prognostication and guiding diagnostics, treatment decisions, and follow-up, as well as informing supportive care interventions. Geriatric assessment and management (GAM) refers to the comprehensive evaluation of an older individual's health status with subsequent management plans focusing on both oncologic and non-oncologic interventions. In 2019, the European Society for Medical Oncology (ESMO) and the International Society of Geriatric Oncology (SIOG) established the ESMO/SIOG Cancer in the Elderly Working Group. This position paper reflects the recommendations of the working group. Our paper summarizes the existing evidence with a focus on recent key trials and based on this, we propose several recommendations and future directions.
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Affiliation(s)
- K P Loh
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, USA.
| | - G Liposits
- Department of Oncology, Odense University Hospital, Odense, Denmark. https://twitter.com/G_LipositsMD
| | - S P Arora
- Division of Hematology/Oncology, Department of Medicine, Mays Cancer Center, University of Texas Health San Antonio, San Antonio, USA. https://twitter.com/DrSukeshiArora
| | - N R Neuendorff
- Department of Geriatrics, Marien Hospital Herne, University Hospital, Ruhr University Bochum, Herne, Germany. https://twitter.com/neuendorff_nr
| | - F Gomes
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester; Senior Adult Oncology, The Christie NHS Foundation Trust, Manchester, UK. https://twitter.com/FabioGomes_go
| | - J L Krok-Schoen
- Comprehensive Cancer Center, The Ohio State University, Columbus; School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, USA. https://twitter.com/KrokSchoen
| | - T Amaral
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany. https://twitter.com/TeeresaSAmaral
| | - E Mariamidze
- Todua Clinic-Department of Oncology and Hematology, Tbilisi, Georgia; Ospedale Policlinico San Martino-Clinica di Oncologia Medica, Genoa. https://twitter.com/EMariamidze
| | - L Biganzoli
- "Sandro Pitigliani" Department of Medical Oncology, Hospital of Prato, Prato, Italy
| | - E Brain
- Department of Medical Oncology, Institut Curie/Saint-Cloud, Saint-Cloud. https://twitter.com/EtienneB66
| | - C Baldini
- Drug Development Department (DITEP), Gustave Roussy, Villejuif; Paris Saclay University, Villejuif, France. https://twitter.com/CapuBaldini
| | - N M L Battisti
- Department of Medicine, The Royal Marsden NHS Foundation Trust, London, UK. https://twitter.com/nicolobattisti
| | - M Frélaut
- Department of Medical Oncology, Gustave Roussy, Villejuif, France. https://twitter.com/frelaut_m
| | - R Kanesvaran
- Department of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore. https://twitter.com/ravikanesvaran
| | - A R A Mislang
- College of Medicine and Public Health, Flinders University, Adelaide; Department of Medical Oncology, Flinders Centre for Innovation in Cancer, Adelaide, Australia. https://twitter.com/AnnaMislang
| | - D Papamichael
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, Nicosia, Cyprus
| | - C Steer
- Border Medical Oncology, Albury Wodonga Regional Cancer Centre, Albury; UNSW School of Clinical Medicine, Rural Clinical Campus, Albury; John Richards Centre for Rural Ageing Research, La Trobe University, Wodonga, Australia. https://twitter.com/drcbsteer
| | - S Rostoft
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo; Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway. https://twitter.com/SRostoft
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Anwar MR, Yeretzian ST, Ayala AP, Matosyan E, Breunis H, Bote K, Puts M, Habib MH, Li Q, Sahakyan Y, Alibhai SMH, Abrahamyan L. Effectiveness of geriatric assessment and management in older cancer patients: a systematic review and meta-analysis. J Natl Cancer Inst 2023; 115:1483-1496. [PMID: 37738290 DOI: 10.1093/jnci/djad200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Frailty and multimorbidity among older cancer patients affect treatment tolerance and efficacy. Comprehensive geriatric assessment and management is recommended to optimize cancer treatment, but its effect on various outcomes remains uncertain. OBJECTIVE Our objective was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) and cost-effectiveness studies comparing comprehensive geriatric assessment (with or without implementation of recommendations) to usual care in older cancer patients. METHODS We searched MEDLINE, EMBASE, CINAHL, and Cochrane trials from inception to January 27, 2023, for RCTs and cost-effectiveness studies. Pooled estimates for outcomes were calculated using random-effects models. RESULTS A total of 19 full-text articles representing 17 RCTs were included. Average participant age was 72-80 years, and 31%-62% were female. Comprehensive geriatric assessment type, mode of delivery, and evaluated outcomes varied across studies. Meta-analysis revealed no difference in risk of mortality (risk ratio [RR] = 1.08. 95% confidence interval [CI] = 0.91 to 1.29), hospitalization (RR = 0.92, 95% CI = 0.77 to 1.10), early treatment discontinuation (RR = 0.89, 95% CI = 0.67 to 1.19), initial dose reduction (RR = 0.99, 95% CI = 0.99 to 1.26), and subsequent dose reduction (RR = 0.87, 95% CI = 0.70 to 1.09). However, the risk of treatment toxicity was statistically significantly lower in the comprehensive geriatric assessment group (RR = 0.78, 95% CI = 0.70 to 0.86). No cost-effectiveness studies were identified. CONCLUSION Compared with usual care, comprehensive geriatric assessment was not associated with a difference in risk of mortality, hospitalization, treatment discontinuation, and dose reduction but was associated with a lower risk of treatment toxicity indicating its potential to optimize cancer treatment in this population. Further research is needed to evaluate cost-effectiveness.
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Affiliation(s)
- Mohammed Rashidul Anwar
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Ana Patricia Ayala
- Gerstein Science Information Centre, University of Toronto, Toronto, ON, Canada
| | | | - Henriette Breunis
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
| | - Kathyrin Bote
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | | | - Qixuan Li
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Yeva Sahakyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, ON, Canada
| | - Shabbir M H Alibhai
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lusine Abrahamyan
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
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Kinsey D, Febrey S, Briscoe S, Kneale D, Thompson Coon J, Carrieri D, Lovegrove C, McGrath J, Hemsley A, Melendez-Torres GJ, Shaw L, Nunns M. Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-164. [PMID: 38140881 DOI: 10.3310/ghty5117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Objectives To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes. Review methods We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis. Results Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation. Discussion Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital. Study registration This trial is registered as PROSPERO registration number CRD42021230620. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Debbie Kinsey
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Samantha Febrey
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Dylan Kneale
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | - Jo Thompson Coon
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Daniele Carrieri
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Christopher Lovegrove
- School of Health Professions, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
| | - John McGrath
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Liz Shaw
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Michael Nunns
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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Yan E, Veitch M, Saripella A, Alhamdah Y, Butris N, Tang-Wai DF, Tartaglia MC, Nagappa M, Englesakis M, He D, Chung F. Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis. J Clin Anesth 2023; 90:111221. [PMID: 37515876 DOI: 10.1016/j.jclinane.2023.111221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
STUDY OBJECTIVE To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients. DESIGN A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022. SETTING Postoperative assessments. PATIENTS Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded. MEASUREMENTS Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI. MAIN RESULTS Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00). CONCLUSIONS Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.
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Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Matthew Veitch
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yasmin Alhamdah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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Yürek F, Marschall U, Gaedigk U, Krüger S, Höft M, Spies C. [Quality Contract for the Prevention of Postoperative Delirium]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:525-539. [PMID: 37725993 DOI: 10.1055/a-2065-3806] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Delirium is one of the most common postoperative complications. Delayed initiation of treatment leads to an increased mortality rate within the first 90 days and to an increased need for post-hospital care. Similarly, neurocognitive disorders (NCDs) occur in a quarter of affected patients over the long-term. The use of evidence-based guideline recommendations can reduce incidence rates of delirium, shorten delirium duration, and prevent complications. Implementing delirium management according to evidence-based guideline recommendations requires a transformation process that integrates all stakeholders. In May 2017, the Federal Joint Committee (G-BA), the highest decision-making body in the German healthcare system, approved the quality contract (QC) as a new instrument for improving healthcare in Germany. With QC, hospitals have the opportunity to set up better conditions for the transformation process of delirium management, because with QC funding, initial hurdles can be more easily overcome, such as establishing and sustaining new structures or mobilizing resources. The cooperation of all stakeholders - but above all their shared understanding - of the need for transformation is crucial for the successful implementation of delirium management. The digitization of cross-departmental processes in particular is an elementary component in a modern transformation process. This creates new opportunities and processes that offer added value for patients and caregivers. Patients thus experience delirium management as a coherent interdisciplinary and multiprofessional concept that is implemented transparently, comprehensibly, and evidence-based.
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Matsuda Y, Tanimukai H, Inoue S, Hirayama T, Kanno Y, Kitaura Y, Inada S, Sugano K, Yoshimura M, Harashima S, Wada S, Hasegawa T, Okamoto Y, Dotani C, Takeuchi M, Kako J, Sadahiro R, Kishi Y, Uchida M, Ogawa A, Inagaki M, Okuyama T. A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements. Jpn J Clin Oncol 2023; 53:808-822. [PMID: 37190819 DOI: 10.1093/jjco/hyad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made. METHODS The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements. RESULTS This article provides a compendium of the recommendations along with their rationales, as well as a short summary. CONCLUSIONS These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Hitoshi Tanimukai
- Faculty of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Inoue
- Department of Neuropsychiatry, Okayama University Hospital, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Takatoshi Hirayama
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yusuke Kanno
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Kitaura
- Department of Psychiatry, Panasonic Health Insurance Organization Matsushita Memorial Hospital, Moriguchi, Japan
| | - Shuji Inada
- Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Koji Sugano
- Division of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Masafumi Yoshimura
- Department of Occupational Therapy, Faculty of Rehabilitation, Kansai Medical University, Hirakata, Japan
| | - Saki Harashima
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saho Wada
- Department of Neuropsychiatry, Nippon Medical School Tamanagayama Hospital, Tokyo, Japan
| | - Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Yoshiaki Okamoto
- Department of pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Chikako Dotani
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Mari Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Asao Ogawa
- Division of Psycho-Oncology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Masatoshi Inagaki
- Department of Psychiatry, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Toru Okuyama
- Department of Psychiatry/Palliative Care Center, Nagoya City University West Medical Center, Nagoya, Japan
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Leinert C, Fotteler M, Kocar TD, Dallmeier D, Kestler HA, Wolf D, Gebhard F, Uihlein A, Steger F, Kilian R, Mueller-Stierlin AS, Michalski CW, Mihaljevic A, Bolenz C, Zengerling F, Leinert E, Schütze S, Hoffmann TK, Onder G, Andersen-Ranberg K, O’Neill D, Wehling M, Schobel J, Swoboda W, Denkinger M. Supporting SURgery with GEriatric Co-Management and AI (SURGE-Ahead): A study protocol for the development of a digital geriatrician. PLoS One 2023; 18:e0287230. [PMID: 37327245 PMCID: PMC10275448 DOI: 10.1371/journal.pone.0287230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/18/2023] Open
Abstract
INTRODUCTION Geriatric co-management is known to improve treatment of older adults in various clinical settings, however, widespread application of the concept is limited due to restricted resources. Digitalization may offer options to overcome these shortages by providing structured, relevant information and decision support tools for medical professionals. We present the SURGE-Ahead project (Supporting SURgery with GEriatric co-management and Artificial Intelligence) addressing this challenge. METHODS A digital application with a dashboard-style user interface will be developed, displaying 1) evidence-based recommendations for geriatric co-management and 2) artificial intelligence-enhanced suggestions for continuity of care (COC) decisions. The development and implementation of the SURGE-Ahead application (SAA) will follow the Medical research council framework for complex medical interventions. In the development phase a minimum geriatric data set (MGDS) will be defined that combines parametrized information from the hospital information system with a concise assessment battery and sensor data. Two literature reviews will be conducted to create an evidence base for co-management and COC suggestions that will be used to display guideline-compliant recommendations. Principles of machine learning will be used for further data processing and COC proposals for the postoperative course. In an observational and AI-development study, data will be collected in three surgical departments of a University Hospital (trauma surgery, general and visceral surgery, urology) for AI-training, feasibility testing of the MGDS and identification of co-management needs. Usability will be tested in a workshop with potential users. During a subsequent project phase, the SAA will be tested and evaluated in clinical routine, allowing its further improvement through an iterative process. DISCUSSION The outline offers insights into a novel and comprehensive project that combines geriatric co-management with digital support tools to improve inpatient surgical care and continuity of care of older adults. TRIAL REGISTRATION German clinical trials registry (Deutsches Register für klinische Studien, DRKS00030684), registered on 21st November 2022.
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Affiliation(s)
- Christoph Leinert
- Institute for Geriatric Research at AGAPLESION Bethesda Ulm, Ulm University Medical Center, Ulm, Germany
- Geriatric Center Ulm, Ulm, Germany
| | - Marina Fotteler
- Institute for Geriatric Research at AGAPLESION Bethesda Ulm, Ulm University Medical Center, Ulm, Germany
- Geriatric Center Ulm, Ulm, Germany
- DigiHealth Institute, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany
| | - Thomas Derya Kocar
- Institute for Geriatric Research at AGAPLESION Bethesda Ulm, Ulm University Medical Center, Ulm, Germany
- Geriatric Center Ulm, Ulm, Germany
| | - Dhayana Dallmeier
- Institute for Geriatric Research at AGAPLESION Bethesda Ulm, Ulm University Medical Center, Ulm, Germany
- Geriatric Center Ulm, Ulm, Germany
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Hans A. Kestler
- Institute for Medical Systems Biology, Ulm University, Ulm, Germany
| | - Dennis Wolf
- Institute for Medical Systems Biology, Ulm University, Ulm, Germany
| | - Florian Gebhard
- Department for Orthopedic Trauma, Ulm University Medical Center, Ulm, Germany
| | - Adriane Uihlein
- Department for Orthopedic Trauma, Ulm University Medical Center, Ulm, Germany
| | - Florian Steger
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Ulm, Germany
| | - Reinhold Kilian
- Department of Psychiatry and Psychiatry II, Section of Health Economics and Health Services Research, Ulm University, Guenzburg, Germany
| | - Annabel S. Mueller-Stierlin
- Department of Psychiatry and Psychiatry II, Section of Health Economics and Health Services Research, Ulm University, Guenzburg, Germany
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | | | - André Mihaljevic
- Department of General and Visceral Surgery, Ulm University Hospital, Ulm, Germany
| | | | | | - Elena Leinert
- Department of Gynecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - Sabine Schütze
- Department of Gynecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - Thomas K. Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Hospital, Ulm, Germany
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-metabolic Diseases and Aging, Instituto Superiore di Sanità, Rome, Italy
| | - Karen Andersen-Ranberg
- Geriatric Research Unit, Department of Clinical Research, Faculty of Health, University of Southern Denmark, Odense, Denmark
| | - Desmond O’Neill
- Centre for Ageing, Neuroscience and the Humanities, Trinity College Dublin, Dublin, Ireland
| | - Martin Wehling
- Working Group FORTA, Faculty of Medicine Mannheim, Ruprecht-Karls-University of Heidelberg, Mannheim, Germany
| | - Johannes Schobel
- DigiHealth Institute, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany
| | - Walter Swoboda
- DigiHealth Institute, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany
| | - Michael Denkinger
- Institute for Geriatric Research at AGAPLESION Bethesda Ulm, Ulm University Medical Center, Ulm, Germany
- Geriatric Center Ulm, Ulm, Germany
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Hsu T, Elias R, Swartz K, Chapman A. Developing Sustainable Cancer and Aging Programs. Am Soc Clin Oncol Educ Book 2023; 43:e390980. [PMID: 37155945 DOI: 10.1200/edbk_390980] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Geriatric assessment (GA) has been shown to decrease toxicity from systemic therapy, improve completion of chemotherapy, and reduce hospitalizations in older adults with cancer. Given the aging of the cancer population, this has the potential to have a positive impact on the care of a large swath of patients seen. Despite endorsement by several international societies, including the American Society of Clinical Oncology, uptake of GA has been low. Lack of knowledge, time, and resources has been cited as reasons for this. Although challenges to developing and implementing a cancer and aging program vary depending on the health care context, GA is adaptable to every health care context from low- to high-resource settings, as well as those in which geriatric oncology is a well-established or just emerging field. We provide an approach for clinicians and administrators to develop, implement, and sustain aging and cancer programs in a doable and sustainable way.
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Affiliation(s)
- Tina Hsu
- The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON, Canada
| | - Rawad Elias
- Hartford HealthCare Cancer Institute, Hartford, CT
- University of Connecticut School of Medicine, Farmington, CT
| | - Kristine Swartz
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Jefferson Health, Philadelphia, PA
| | - Andrew Chapman
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Jefferson Health, Philadelphia, PA
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Gagesch M, Rösler W, Bauernschmitt R, Wilhelm MJ, Freystätter G. [Benefit of a Geriatric Evaluation before Operations, Interventions and Oncological Therapies]. PRAXIS 2023; 112:340-347. [PMID: 37042406 DOI: 10.1024/1661-8157/a004050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Benefit of a Geriatric Evaluation before Operations, Interventions and Oncological Therapies Abstract: Older patients face an increased risk of complications and adverse outcomes during and after operations, interventions, and intense oncological therapies. At the same time, this patient group should not be excluded per se from potentially beneficial medical procedures based on chronological age alone. The timely identification of geriatric syndromes and increased vulnerability by means of comprehensive geriatric assessment is becoming increasingly important and is already recommended in the guidelines of professional societies of several medical disciplines. Nonetheless, the geriatric assessment should ideally be followed by proactive co-management in the sense of integrated care. The establishment of interdisciplinary and integrated care pathways for older hospital patients can contribute to significantly improved treatment outcomes. In addition to better patient-related outcomes and rising quality indicators, this approach may also offer positive health economic effects.
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Affiliation(s)
- Michael Gagesch
- Klinik für Altersmedizin, Universitätsspital Zürich, Zürich, Schweiz
- Zentrum Alter und Mobilität, Universitätsspital Zürich, Zürich, Schweiz
| | - Wiebke Rösler
- Klinik für Medizinische Onkologie und Hämatologie, Universitätsspital Zürich, Zürich, Schweiz
| | | | - Markus J Wilhelm
- Klinik für Herzchirurgie, Universitätsspital Zürich, Zürich, Schweiz
| | - Gregor Freystätter
- Klinik für Altersmedizin, Universitätsspital Zürich, Zürich, Schweiz
- Zentrum Alter und Mobilität, Universitätsspital Zürich, Zürich, Schweiz
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Preoperative Risk Factors Associated with Increased Incidence of Postoperative Delirium: Systematic Review of Qualified Clinical Studies. Geriatrics (Basel) 2023; 8:geriatrics8010024. [PMID: 36826366 PMCID: PMC9956273 DOI: 10.3390/geriatrics8010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/20/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Postoperative delirium (POD) is an acute alteration of mental state, characterized by reduced awareness and attention, occurring up to five postoperative days after recovery from anesthesia. Several original studies and reviews have identified possible perioperative POD risk factors; however, there is no comprehensive review of the preoperative risk factors in patients diagnosed with POD using only validated diagnostic scales. The aim of this systematic review was to report the preoperative risk factors associated with an increased incidence of POD in patients undergoing non-cardiac and non-brain surgery. The reviewed studies included original research papers that used at least one validated diagnostic scale to identify POD occurrence for more than 24 h. A total of 6475 references were retrieved from the database search, with only 260 of them being suitable for further review. Out of the 260 reviewed studies, only 165 that used a validated POD scale reported one or more preoperative risk factors. Forty-one risk factors were identified, with various levels of statistical significance. The extracted risk factors could serve as a preoperative POD risk assessment workup. Future studies dedicated to the further evaluation of the specific preoperative risk factors' contributions to POD could help with the development of a weighted screening tool.
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Comprehensive geriatric assessment and multidisciplinary team interventions for hospitalized older adults: A scoping review. Arch Gerontol Geriatr 2023; 104:104831. [PMID: 36279806 DOI: 10.1016/j.archger.2022.104831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND/OBJECTIVES Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic and treatment process to evaluate medical, psychosocial, and functional capability. It is useful to develop a coordinated and integrated plan for frail older patients. This study aimed to examine the current scope of CGA based multidisciplinary team interventions in acute care setting to improve the health outcomes for older adults. METHODS We searched electronic databases: PubMed, Ovid, PsychINFO, Scopus, RISS and KoreaMed from 2011 to 2021. The selected articles were extracted by three reviewers and cross checked by the fourth reviewer to resolve any conflicts. Data were synthesized and analyzed descriptively and thematically. Articles are nested three themes: inpatient (IN), emergency room (ER) and oncology patient (ONCO). RESULTS Of the 1830 articles that were screened, 710 were potentially eligible. Finally, 26 articles were selected and categorized as IN (n=8), ER (n=7) and ONCO (n=11). Geriatricians and nurses participated in most of the multidisciplinary teams followed by other health professionals. The most effective primary outcomes were focused and retrieved across five domains, screening, prevention, treatment, quality of care, and rehabilitation. The subdomains are problem lists which is common and problematic among hospitalized older patients and retrieved from the most commonly used multidisciplinary interventions according to each domain. CONCLUSION CGA based multidimensional intervention (MDI) are likely to be an effective in care of older adults. There is remarkable paradigm shift required to improve better health outcomes for hospitalized older adults. It also suggests that there is a need to design the CGA based MDI to build a standardized protocol for older adults to maintain functional capacity and increase likelihood of living in their own home.
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Geriatric assessment in the management of older patients with cancer – A systematic review (update). J Geriatr Oncol 2022; 13:761-777. [DOI: 10.1016/j.jgo.2022.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2022]
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Giannotti C, Massobrio A, Carmisciano L, Signori A, Napolitano A, Pertile D, Soriero D, Muzyka M, Tagliafico L, Casabella A, Cea M, Caffa I, Ballestrero A, Murialdo R, Laudisio A, Incalzi RA, Scabini S, Monacelli F, Nencioni A. Effect of Geriatric Comanagement in Older Patients Undergoing Surgery for Gastrointestinal Cancer: A Retrospective, Before-and-After Study. J Am Med Dir Assoc 2022; 23:1868.e9-1868.e16. [DOI: 10.1016/j.jamda.2022.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
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Geriatric assessment-informed treatment decision making and downstream outcomes: what are the research priorities? Curr Opin Support Palliat Care 2022; 16:25-32. [DOI: 10.1097/spc.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The detection of delirium in admitted oncology patients: a scoping review. Eur Geriatr Med 2022; 13:33-51. [PMID: 35032322 PMCID: PMC8860783 DOI: 10.1007/s41999-021-00586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
Aim To understand the validation of delirium detection tools in medical oncology, as well as identify data on incidence, prevalence and reversibility in this setting. Findings Of twelve studies, only four used case ascertainment methods following published recommendations, six studies had a low risk of bias. Message In delirium tool validation studies in the oncology setting, choice of appropriate gold standard for case ascertainment is a critical factor. New tools and new validations are not recommended, rather the critical application of existing tools depending on appropriate validation and clinical practicality for the setting. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1. Purpose Delirium leads to poor outcomes for patients and careers and has negative impacts on staff and service provision. Cancer rates in elderly populations are increasing and frequently, cancer diagnoses are a co-morbidity in the context of frailty. Data relating to the epidemiology of delirium in hospitalised cancer patients are limited. With the overarching purpose of improving delirium detection and reducing the morbidity and mortality of delirium in cancer patients, we reviewed the epidemiological data and approach to delirium detection in hospitalised, adult oncology patients. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, and SCOPUS databases were searched from January 1996 to August 2017. Key concepts were delirium, cancer, inpatient oncology and delirium screening/detection. Results Of 896 unique studies identified; 91 met full-text review criteria. Of 12 eligible studies, four applied recommended case ascertainment methods to all patients, three used delirium screening tools alone or with case ascertainment tools sub-optimally applied, four used tools not recommended for delirium screening or case ascertainment, one used the Confusion Assessment Method with insufficient information to determine if it met case ascertainment status. Two studies presented delirium incidence rates: 7.8%, and 17% respectively. Prevalence rates ranged from 18–33% for general medical or oncology wards; 42–58% for Acute Palliative Care Units (APCU); and for older cancer patients: 22% and 57%. Three studies reported reversibility; 26% and 49% respectively (APCUs) and 30% (older patients with cancer). Six studies had a low risk of bias according to QUADAS-2 criteria; all studies in the APCU setting were rated at higher risk of bias. Tool selection, study flow and recruitment bias reduced study quality. Conclusion The knowledge base for improved interventions and clinical care for adults with cancer and delirium is limited by the low number of studies. A clear distinction between screening tools and diagnostic tools is required to provide an improved understanding of the rates of delirium and its reversibility in this population. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00586-1.
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Nipp RD, Qian CL, Knight HP, Ferrone CR, Kunitake H, Castillo CFD, Lanuti M, Qadan M, Ricciardi R, Lillemoe KD, Temel B, Hashmi AZ, Scott E, Stevens E, Williams GR, Fong ZV, O'Malley TA, Franco-Garcia E, Horick NK, Jackson VA, Greer JA, El-Jawahri A, Temel JS. Effects of a perioperative geriatric intervention for older adults with Cancer: A randomized clinical trial. J Geriatr Oncol 2022; 13:410-415. [PMID: 35074322 PMCID: PMC9058195 DOI: 10.1016/j.jgo.2022.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/27/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Older adults with gastrointestinal cancers undergoing surgery often experience poor outcomes, such as prolonged postoperative hospital length of stay (LOS), intensive care unit (ICU) use, hospital readmissions, and complications. Involvement of geriatricians in the care of older adults with cancer can improve outcomes. We conducted a randomized trial of a perioperative geriatric intervention (PERI-OP) in older patients with gastrointestinal cancer undergoing surgery. METHODS From 9/2016-4/2019, we randomly assigned patients age ≥ 65 with gastrointestinal cancer planning to undergo surgical resection to receive PERI-OP or usual care. Patients assigned to PERI-OP met with a geriatrician preoperatively in the outpatient setting and postoperatively as an inpatient consultant. The primary outcome was postoperative hospital LOS. Secondary outcomes included postoperative ICU use, 90-day hospital readmission rates, and complication rates. We conducted intention-to-treat (ITT) and per-protocol (PP) analyses. RESULTS ITT analyses included 137/160 patients who underwent surgery (usual care = 68/78, intervention = 69/82). PP analyses included the 68 usual care patients and the 30/69 intervention patients who received the preoperative and postoperative intervention components. ITT analyses demonstrated no significant differences between intervention and usual care in postoperative hospital LOS (7.23 vs 8.21 days, P = 0.374), ICU use (23.2% vs 32.4%, P = 0.257), 90-day hospital readmission rates (21.7% vs 25.0%, P = 0.690), or complication rates (17.4% vs 20.6%, P = 0.668). In PP analyses, intervention patients had shorter postoperative hospital LOS (5.90 vs 8.21 days, P = 0.024), but differences in ICU use (13.3% vs 32.4%, P = 0.081), 90-day hospital readmission rates (16.7% vs 25.0%, P = 0.439), and complication rates (6.7% vs 20.6%, P = 0.137) remained non-significant. CONCLUSIONS In this randomized trial, PERI-OP did not have a significant impact on postoperative hospital LOS, ICU use, hospital readmissions, or complications. However, the subgroup who received PERI-OP as planned experienced encouraging results. Future studies of PERI-OP should include efforts, such as telehealth, to ensure the intervention is delivered as planned.
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Burton JK, Craig L, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2021; 11:CD013307. [PMID: 34826144 PMCID: PMC8623130 DOI: 10.1002/14651858.cd013307.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU). SEARCH METHODS We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium. DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium. MAIN RESULTS We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies. Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias). There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision). No studies of multicomponent interventions reported data on new diagnoses of dementia. Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm. Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias). Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Shun Qi Yong
- MVLS, College of Medicine and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Elizabeth A Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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22
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Wilson S, Sutherland E, Razak A, O'Brien M, Ding C, Nguyen T, Rosenkranz P, Sanchez SE. Implementation of a Frailty Assessment and Targeted Care Interventions and Its Association with Reduced Postoperative Complications in Elderly Surgical Patients. J Am Coll Surg 2021; 233:764-775.e1. [PMID: 34438081 DOI: 10.1016/j.jamcollsurg.2021.08.677] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/07/2021] [Accepted: 08/05/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Older patients with frailty syndrome have a greater risk of poor postoperative outcomes. In this study, we used a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to implement an assessment tool to identify frail patients and targeted interventions to improve their outcomes. STUDY DESIGN We implemented a 5-question frailty assessment tool for patients 65 years and older admitted to the general and vascular surgery services from January 1, 2018 to December 31, 2019. Identified frail patients received evidence-based clinical orders and nursing care plan interventions tailored to optimize recovery. A RE-AIM framework was used to assess implementation effectiveness through provider and nurse surveys, floor audits, and chart review. RESULTS Of 1,158 patients included in this study, 696 (60.1%) were assessed for frailty. Among these, 611 patients (87.8%) scored as frail or intermediately frail. After implementation, there were significant increases in the completion rates of frailty-specific care orders for frail patients, including delirium precautions (52.1% vs 30.7%; p < 0.001), aspiration precautions (50.0% vs 26.9%; p < 0.001), and avoidance of overnight vitals (32.5% vs 0%). Floor audits, however, showed high variability in completion of care plan components by nursing staff. Multivariate analysis showed significant decreases in 30-day complication rates (odds ratio 0.532; p < 0.001) after implementation. CONCLUSIONS A frailty assessment was able to identify elderly patients for provision of targeted, evidence-based frailty care. Despite limited uptake of the assessment by providers and completion of care plan components by nursing staff, implementation of the assessment and care interventions was associated with substantial decreases in complications among elderly surgical patients.
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Affiliation(s)
- Spencer Wilson
- Department of Surgery, Boston Medical Center, Boston, MA.
| | | | - Alina Razak
- Boston University School of Medicine, Boston, MA
| | | | - Callie Ding
- Boston University School of Medicine, Boston, MA
| | - Thien Nguyen
- Boston University School of Medicine, Boston, MA
| | - Pam Rosenkranz
- Department of Surgery, Boston Medical Center, Boston, MA
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston, MA; Boston University School of Medicine, Boston, MA
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23
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Informational support for depression and quality of life improvements in older patients with cancer: a systematic review and meta-analysis. Support Care Cancer 2021; 30:1065-1077. [PMID: 34415425 DOI: 10.1007/s00520-021-06494-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/07/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE To assess and summarize the effects of informational support on depression and quality of life of older patients with cancer. METHODS PubMed, MEDLINE, and Web of Science were searched to identify articles written in English and published until March 2021. Studies within 10 years period (2010-2021) were included. Randomized controlled trials were included if they evaluated the impact of informational support on depression and quality of life. All analyses were performed with Review Manager 5.3. RESULTS Twelve studies with a total of 2374 participants met the inclusion criteria. Our primary outcomes included depression and quality of life. (1) Depression: results indicated no statistically significant difference and low heterogeneity [SMD = 0.28, 95% CI (- 0.24,0.80), p = 0.45; I2 = 0%], (2) Quality of life: in the subgroup analyses of EORTC QLQ-C30, results indicated a significant effect of informational support on quality of life [SMD = 2.84, 95% CI (0.63, 5.05), p = 0.03; I2 = 79%]; in the subgroup analyses of FACT and SF-36, there were no significance. CONCLUSIONS Informational support could reduce depression and did improve the quality of life in older cancer patients with statistical significance. The findings suggested that informational support was an effective approach to improve depression and quality of life in older patients with cancer.
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24
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Burton JK, Craig LE, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2021; 7:CD013307. [PMID: 34280303 PMCID: PMC8407051 DOI: 10.1002/14651858.cd013307.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU). SEARCH METHODS We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium. DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium. MAIN RESULTS We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies. Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias). There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision). No studies of multicomponent interventions reported data on new diagnoses of dementia. Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm. Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias). Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.
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Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Louise E Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Shun Qi Yong
- MVLS, College of Medicine and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Elizabeth A Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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25
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Rostoft S, O'Donovan A, Soubeyran P, Alibhai SMH, Hamaker ME. Geriatric Assessment and Management in Cancer. J Clin Oncol 2021; 39:2058-2067. [PMID: 34043439 DOI: 10.1200/jco.21.00089] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anita O'Donovan
- Applied Radiation Therapy Trinity, Trinity St James's Cancer Institute, Trinity College Dublin, Dublin, Ireland
| | - Pierre Soubeyran
- Department of Medical Oncology, Institut Bergonié, Université de Bordeaux, Inserm U1218, Bordeaux, France
| | - Shabbir M H Alibhai
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Internal Medicine and Geriatrics, University Health Network, Toronto, ON, Canada
| | - Marije E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis, Utrecht, the Netherlands
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26
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Saripella A, Wasef S, Nagappa M, Riazi S, Englesakis M, Wong J, Chung F. Effects of comprehensive geriatric care models on postoperative outcomes in geriatric surgical patients: a systematic review and meta-analysis. BMC Anesthesiol 2021; 21:127. [PMID: 33888071 PMCID: PMC8061210 DOI: 10.1186/s12871-021-01337-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/09/2021] [Indexed: 12/12/2022] Open
Abstract
Background The elderly population is highly susceptible to develop post-operative complications after major surgeries. It is not clear whether the comprehensive geriatric care models are effective in reducing adverse events. The objective of this systematic review and meta-analysis is to determine whether the comprehensive geriatric care models improved clinical outcomes, particularly in decreasing the prevalence of delirium and length of hospital stay (LOS) in elderly surgical patients. Method We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Emcare Nursing, Web of Science, Scopus, CINAHL, ClinicalTrials. Gov, and ICTRP between 2009 to January 23, 2020. We included studies on geriatric care models in elderly patients (≥60 years) undergoing elective, non-cardiac high-risk surgery. The outcomes were the prevalence of delirium, LOS, rates of 30-days readmission, and 30-days mortality. We used the Cochrane Review Manager Version 5.3. to estimate the pooled Odds Ratio (OR) and Mean Difference (MD) using random effect model analysis. Results Eleven studies were included with 2672 patients [Randomized Controlled Trials (RCTs): 4; Non-Randomized Controlled Trials (Non-RCTs): 7]. Data pooled from six studies showed that there was no significant difference in the prevalence of delirium between the intervention and control groups: 13.8% vs 15.9% (OR: 0.76; 95% CI: 0.30–1.96; p = 0.57). Similarly, there were no significant differences in the LOS (MD: -0.55; 95% CI: − 2.28, 1.18; p = 0.53), 30-day readmission (12.1% vs. 14.3%; OR: 1.09; 95% CI: 0.67–1.77; p = 0.73), and 30-day mortality (3.2% vs. 2.1%; OR: 1.34; 95% CI: 0.66–2.69; p = 0.42). The quality of evidence was very low. Conclusions The geriatric care models involved pre-operative comprehensive geriatric assessment, and intervention tools to address cognition, frailty, and functional status. In non-cardiac high-risk surgeries, these care models did not show any significant difference in the prevalence of delirium, LOS, 30-days readmission rates, and 30-day mortality in geriatric patients. Further RCTs are warranted to evaluate these models on the postoperative outcomes. Trial registration PROSPERO registration number - CRD42020181779. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01337-2.
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Affiliation(s)
- Aparna Saripella
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T2S8, Canada
| | - Sara Wasef
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T2S8, Canada
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St. Joseph Health Care, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Sheila Riazi
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T2S8, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T2S8, Canada.,Department of Anesthesia and Pain Management, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T2S8, Canada.
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27
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Sgnaolin V, Sgnaolin V, Schneider RH. Implicações da avaliação geriátrica ampla na qualidade de vida em pessoas idosas com câncer: uma revisão integrativa. REVISTA BRASILEIRA DE GERIATRIA E GERONTOLOGIA 2021. [DOI: 10.1590/1981-22562021024.200297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Resumo A avaliação geriátrica ampla (AGA) melhora a qualidade do cuidado das pessoas idosas com câncer, pois permite a identificação de problemas geriátricos e fragilidades que tenham implicações na saúde do indivíduo. Apesar dos benefícios da AGA, dificuldades relacionadas ao tempo e gastos com essa ferramenta limitam sua implantação na prática. O objetivo desta revisão é avaliar a relação entre a AGA e a qualidade de vida (QV) de pessoas idosas com câncer, através de uma revisão integrativa da literatura. Foi realizada uma busca por artigos nas bases de dados PubMed, MEDLINE, IBECS e LILACS, publicados entre 2015 e 2020, que abordassem as implicações da AGA na QV de pessoas idosas com câncer e, dos 298 estudos encontrados, 21 foram selecionados para análise. Esses demonstraram que a AGA desempenha função importante ao identificar pessoas idosas com maior risco de comprometimento da QV durante a evolução da neoplasia e do tratamento oncológico, bem como ao orientar a indicação de intervenções geriátricas específicas que previnam a deterioração da QV. Assim, a presente revisão destaca a importância da avaliação integral das pessoas idosas com câncer que, através de diferentes âmbitos, sejam prognósticos ou intervencionistas, desenvolve um papel fundamental na preservação da QV dessa população. Compreende-se a necessidade de desenvolver estratégias para incorporação da AGA no cuidado das pessoas idosas com câncer.
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Affiliation(s)
- Valéria Sgnaolin
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Brasil; Hospital Mãe de Deus, Brasil
| | - Vanessa Sgnaolin
- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Brasil
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28
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Interventions to Improve Clinical Outcomes in Older Adults Admitted to a Surgical Service: A Systematic Review and Meta-analysis. J Am Med Dir Assoc 2020; 21:1833-1843.e20. [DOI: 10.1016/j.jamda.2020.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/12/2020] [Accepted: 03/21/2020] [Indexed: 12/12/2022]
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29
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León‐Salas B, Trujillo‐Martín MM, Martínez del Castillo LP, García‐García J, Pérez‐Ros P, Rivas‐Ruiz F, Serrano‐Aguilar P. Multicomponent Interventions for the Prevention of Delirium in Hospitalized Older People: A Meta‐Analysis. J Am Geriatr Soc 2020; 68:2947-2954. [DOI: 10.1111/jgs.16768] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/07/2020] [Accepted: 07/14/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Beatriz León‐Salas
- Canarian Foundation Institute of Health Research of Canary Islands (FIISC) Santa Cruz de Tenerife Spain
- Health Services and Chronic Diseases Research Network (REDISSEC) Santa Cruz de Tenerife Spain
| | - María M. Trujillo‐Martín
- Canarian Foundation Institute of Health Research of Canary Islands (FIISC) Santa Cruz de Tenerife Spain
- Health Services and Chronic Diseases Research Network (REDISSEC) Santa Cruz de Tenerife Spain
- Centre for Biomedical Research of the Canary Islands (CIBICAN) Santa Cruz de Tenerife Spain
| | | | - Javier García‐García
- Quality and Patient Safety Unit Nuestra Señora de Candelaria University Hospital Santa Cruz de Tenerife Spain
| | - Pilar Pérez‐Ros
- Department of Nursing Universidad Católica de Valencia San Vicente Mártir Valencia Spain
| | - Francisco Rivas‐Ruiz
- Health Services and Chronic Diseases Research Network (REDISSEC) Santa Cruz de Tenerife Spain
- Costa del Sol Health Agency Malaga Spain
| | - Pedro Serrano‐Aguilar
- Health Services and Chronic Diseases Research Network (REDISSEC) Santa Cruz de Tenerife Spain
- Centre for Biomedical Research of the Canary Islands (CIBICAN) Santa Cruz de Tenerife Spain
- Evaluation Service of the Canary Islands Health Service (SESCS) Canary Islands Health Service Santa Cruz de Tenerife Spain
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30
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Janssen TL, Steyerberg EW, van Hoof-de Lepper CCHA, Seerden TCJ, de Lange DC, Wijsman JH, Ho GH, Gobardhan PD, van der Laan L. Long-term outcomes of major abdominal surgery and postoperative delirium after multimodal prehabilitation of older patients. Surg Today 2020; 50:1461-1470. [PMID: 32542413 DOI: 10.1007/s00595-020-02044-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/09/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The long-term outcomes of surgery followed by delirium after multimodal prehabilitation program are largely unknown. We conducted this study to assess the effects of prehabilitation on 1-year mortality and of postoperative delirium on 1-year mortality and functional outcomes. METHODS The subjects of this study were patients aged ≥ 70 years who underwent elective surgery for abdominal aortic aneurysm (AAA) or colorectal cancer (CRC) between January 2013, and June 2018. A prehabilitation program was implemented in November 2015, which aimed to optimize physical health, nutritional status, factors of frailty and preoperative anemia prior to surgery. The outcomes were assessed as mortality after 6 and 12 months, compared between the two treatment groups; and mortality and functional outcomes, compared between patients with and those without delirium. RESULTS There were 627 patients (controls N = 360, prehabilitation N = 267) included in this study. Prehabilitation did not reduce mortality after 1 year (HR 1.31 [95% CI 0.75-2.30]; p = 0.34). Delirium was significantly associated with 1-year mortality (HR 4.36 [95% CI 2.45-7.75]; p < 0.001) and with worse functional outcomes after 6 and 12 months (KATZ ADL p = 0.013 and p = 0.004; TUG test p = 0.041 and p = 0.011, respectively). CONCLUSIONS The prehabilitation program did not reduce 1-year mortality. Delirium and the burden of comorbidity are both independently associated with an increased risk of 1-year mortality and delirium is associated with worse functional outcomes. TRIAL REGISTRATION Dutch Trial Registration, NTR5932. https://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5932 .
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Affiliation(s)
- Ties L Janssen
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands.
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Tom C J Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, The Netherlands
| | | | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Paul D Gobardhan
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands.,Department of Cardiovascular Science, UZ Leuven, Leuven, Belgium
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Farrington N, Richardson A, Bridges J. Interventions for older people having cancer treatment: A scoping review. J Geriatr Oncol 2020; 11:769-783. [DOI: 10.1016/j.jgo.2019.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/24/2019] [Accepted: 09/25/2019] [Indexed: 01/05/2023]
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Partridge JSL, Aitken RM, Dhesi JK. Perioperative medicine for older people: Learning across continents. Australas J Ageing 2020; 38:228-230. [PMID: 31797515 DOI: 10.1111/ajag.12723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/06/2019] [Accepted: 08/22/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Judith Stephanie Louise Partridge
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Rachel Margaret Aitken
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Aged Care, Caulfield Hospital, Alfred Health, Melbourne, Vic., Australia
| | - Jugdeep Kaur Dhesi
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Division of Surgery and Interventional Science, University College London, London, UK
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Gadzinski AJ, Psutka SP. Risk stratification metrics for bladder cancer: Comprehensive Geriatric Assessments. Urol Oncol 2020; 38:725-733. [PMID: 32037198 DOI: 10.1016/j.urolonc.2020.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/27/2019] [Accepted: 01/08/2020] [Indexed: 12/26/2022]
Abstract
Despite advances in surgical technique and perioperative care pathways, complication rates following radical cystectomy for bladder cancer remain high and perioperative outcomes for elderly patients are suboptimal. Furthermore, subjective risk assessments of patients with bladder cancer, with a high prevalence of complex comorbidity burden and risk of frailty, may result in undertreatment of patients assumed to be poor operative candidates. A critical component of preoperative patient counseling and treatment selection is accurate and objective preoperative risk appraisal. Comprehensive Geriatric Assessments are multi-domain evaluations of the medical, functional, and psychosocial aspects of health designed specifically for use in elderly patients with the objective of identifying vulnerabilities that may be targeted with interventions for improvement. While currently recommended by multiple guideline bodies for use in the preoperative evaluation of elderly patients with bladder cancer there is a paucity of data describing their use in contemporary clinical practice. Herein, then, we will describe the components of a Comprehensive Geriatric Assessments and propose strategies for their integration into the preoperative surgical workflow.
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Affiliation(s)
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA.
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Nunns M, Shaw L, Briscoe S, Thompson Coon J, Hemsley A, McGrath JS, Lovegrove CJ, Thomas D, Anderson R. Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundElective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.ObjectivesTo evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.Data sourcesSeven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.Review methodsComparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.FindingsA total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.LimitationsStudies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.ConclusionsEnhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.Future workFurther studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.Study registrationThis study is registered as PROSPERO CRD42017080637.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Michael Nunns
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - John S McGrath
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Christopher J Lovegrove
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
- School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK
| | - David Thomas
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Anderson
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
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Turner KE, Parlow JL. Sharing the care: anesthesiology as part of the perioperative interdisciplinary team. Can J Anaesth 2019; 66:1018-1021. [PMID: 31290121 DOI: 10.1007/s12630-019-01435-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Kim E Turner
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, Canada.
| | - Joel L Parlow
- Department of Anesthesiology and Perioperative Medicine, Queen's University, 76 Stuart Street, Kingston, ON, Canada
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Postoperative shared-care for patients undergoing non-cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2019; 66:1095-1105. [DOI: 10.1007/s12630-019-01433-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 10/26/2022] Open
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Bentov I, Kaplan SJ, Pham TN, Reed MJ. Frailty assessment: from clinical to radiological tools. Br J Anaesth 2019; 123:37-50. [PMID: 31056240 DOI: 10.1016/j.bja.2019.03.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 02/05/2019] [Accepted: 03/05/2019] [Indexed: 12/21/2022] Open
Abstract
Frailty is a syndrome of cumulative decline across multiple physiological systems, which predisposes vulnerable adults to adverse events. Assessing vulnerable patients can potentially lead to interventions that improve surgical outcomes. Anaesthesiologists who care for older patients can identify frailty to improve preoperative risk stratification and subsequent perioperative planning. Numerous clinical tools to diagnose frailty exist, but none has emerged as the standard tool to be used in clinical practice. Radiological modalities, such as computed tomography and ultrasonography, are widely performed before surgery, and are therefore available to be used opportunistically to objectively evaluate surrogate markers of frailty. This review presents the importance of frailty assessment by anaesthesiologists; lists common clinical tools that have been applied; and proposes that utilising radiological imaging as an objective surrogate measure of frailty is a novel, expanding approach for which anaesthesiologists can significantly contribute to broad implementation.
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Affiliation(s)
- Itay Bentov
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.
| | - Stephen J Kaplan
- Section of General, Thoracic, and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Tam N Pham
- Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - May J Reed
- Division of Gerontology and Geriatric Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
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van Rijckevorsel-Scheele J, Willems RCWJ, Roelofs PDDM, Koppelaar E, Gobbens RJJ, Goumans MJBM. Effects of health care interventions on quality of life among frail elderly: a systematized review. Clin Interv Aging 2019; 14:643-658. [PMID: 31040654 PMCID: PMC6453553 DOI: 10.2147/cia.s190425] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Many health care interventions have been developed that aim to improve or maintain the quality of life for frail elderly. A clear overview of these health care interventions for frail elderly and their effects on quality of life is missing. PURPOSE To provide a systematic overview of the effect of health care interventions on quality of life of frail elderly. METHODS A systematic search was conducted in Embase, Medline (OvidSP), Cochrane Central, Cinahl, PsycInfo and Web of Science, up to and including November 2017. Studies describing health care interventions for frail elderly were included if the effect of the intervention on quality of life was described. The effects of the interventions on quality of life were described in an overview of the included studies. RESULTS In total 4,853 potentially relevant articles were screened for relevance, of which 19 intervention studies met the inclusion criteria. The studies were very heterogeneous in the design: measurement of frailty, health care intervention and outcome measurement differ. Health care interventions described were: multidisciplinary treatment, exercise programs, testosterone gel, nurse home visits and acupuncture. Seven of the nineteen intervention studies, describing different health care interventions, reported a statistically significant effect on subdomains of quality of life, two studies reported a statistically significant effect of the intervention on the overall quality of life score. Ten studies reported no statistically significant difference between the intervention and control groups. CONCLUSION Reported effects of health care interventions on frail elderly persons' quality of life are inconsistent, with most of the studies reporting no differences between the intervention and control groups. As the number of frail elderly persons in the population will continue to grow, it will be important to continue the search for effective health care interventions. Alignment of studies in design and outcome measurements is needed.
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Affiliation(s)
| | - Renate C W J Willems
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands,
| | - Pepijn D D M Roelofs
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands,
| | - Elin Koppelaar
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands,
| | - Robbert J J Gobbens
- Faculty of Health, Sports and Social Work, Inholland University of Applied Sciences, Amsterdam, the Netherlands
- Zonnehuisgroep Amstelland, Amstelveen, the Netherlands
- Department of Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Marleen J B M Goumans
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands,
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The effect of a geriatric evaluation on treatment decisions and outcome for older cancer patients – A systematic review. J Geriatr Oncol 2018; 9:430-440. [DOI: 10.1016/j.jgo.2018.03.014] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/20/2018] [Accepted: 03/22/2018] [Indexed: 12/24/2022]
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Watt J, Tricco AC, Talbot-Hamon C, Pham B, Rios P, Grudniewicz A, Wong C, Sinclair D, Straus SE. Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis. J Gen Intern Med 2018; 33:500-509. [PMID: 29374358 PMCID: PMC5880753 DOI: 10.1007/s11606-017-4204-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 09/22/2017] [Accepted: 09/29/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery. METHODS Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates. RESULTS Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3-23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2-17.9), frailty (OR 4.1, 95% CI 1.4-11.7), cognitive impairment (OR 2.7, 95% CI 1.9-3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6-2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3-2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4-3.6) and smoking status (OR 1.8 95% CI 1.3-2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52-0.91). DISCUSSION Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care.
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Affiliation(s)
- Jennifer Watt
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada.,Institute for Health Policy Management & Evaluation, University of Toronto, 4th Floor, 155 College Street, Toronto, Ontario, M5T 3M6, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.,Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada
| | - Catherine Talbot-Hamon
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada
| | - Ba' Pham
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.,Toronto Health Economics and Technology Assessment Collaborative, Faculty of Pharmacy and Institute of Health Policy Management Evaluation, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2, Canada
| | - Patricia Rios
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Agnes Grudniewicz
- Telfer School of Management, University of Ottawa, 55 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada
| | - Camilla Wong
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Douglas Sinclair
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Sharon E Straus
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada. .,Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.
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Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, Khadaroo RG. Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database Syst Rev 2018; 1:CD012485. [PMID: 29385235 PMCID: PMC6491328 DOI: 10.1002/14651858.cd012485.pub2] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Aging populations are at increased risk of postoperative complications. New methods to provide care for older people recovering from surgery may reduce surgery-related complications. Comprehensive geriatric assessment (CGA) has been shown to improve some outcomes for medical patients, such as enabling them to continue living at home, and has been proposed to have positive impacts for surgical patients. CGA is a coordinated, multidisciplinary collaboration that assesses the medical, psychosocial and functional capabilities and limitations of an older person, with the goal of establishing a treatment plan and long-term follow-up. OBJECTIVES To assess the effectiveness of CGA interventions compared to standard care on the postoperative outcomes of older people admitted to hospital for surgical care. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two clinical trials registers on 13 January 2017. We also searched grey literature for additional citations. SELECTION CRITERIA Randomized trials of people undergoing surgery aged 65 years and over comparing CGA with usual surgical care and reporting any of our primary (mortality and discharge to an increased level of care) or secondary (length of stay, re-admission, total cost and postoperative complication) outcomes. We excluded studies if the participants did not receive a complete CGA, did not undergo surgery, and if the study recruited participants aged less than 65 years or from a setting other than an acute care hospital. DATA COLLECTION AND ANALYSIS Two review authors independently screened, assessed risk of bias, extracted data and assessed certainty of evidence from identified articles. We expressed dichotomous treatment effects as risk ratio (RR) with 95% confidence intervals and continuous outcomes as mean difference (MD). MAIN RESULTS We included eight randomised trials, seven recruited people recovering from a hip fracture (N = 1583) and one elective surgical oncology trial (N = 260), conducted in North America and Europe. For two trials CGA was done pre-operatively and postoperatively for the remaining. Six trials had adequate randomization, five had low risk of performance bias and four had low risk of detection bias. Blinding of participants was not possible. All eight trials had low attrition rates and seven reported all expected outcomes.CGA probably reduces mortality in older people with hip fracture (RR 0.85, 95% CI 0.68 to 1.05; 5 trials, 1316 participants, I² = 0%; moderate-certainty evidence). The intervention reduces discharge to an increased level of care (RR 0.71, 95% CI 0.55 to 0.92; 5 trials, 941 participants, I² = 0%; high-certainty evidence).Length of stay was highly heterogeneous, with mean difference between participants allocated to the intervention and the control groups ranging between -12.8 and 8.3 days. CGA probably leads to slightly reduced length of stay (4 trials, 841 participants, moderate-certainty evidence). The intervention probably makes little or no difference in re-admission rates (RR 1.00, 95% CI 0.76 to 1.32; 3 trials, 741 participants, I² = 37%; moderate-certainty evidence).CGA probably slightly reduces total cost (1 trial, 397 participants, moderate-certainty evidence). The intervention may make little or no difference for major postoperative complications (2 trials, 579 participants, low-certainty evidence) and delirium rates (RR 0.75, 95% CI 0.60 to 0.94, 3 trials, 705 participants, I² = 0%; low-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that CGA can improve outcomes in people with hip fracture. There are not enough studies to determine when CGA is most effective in relation to surgical intervention or if CGA is effective in surgical patients presenting with conditions other than hip fracture.
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Affiliation(s)
| | - Amir Taheri
- University of AlbertaDepartment of SurgeryEdmontonCanada
| | - Sidian S Chen
- University of AlbertaDepartment of SurgeryEdmontonCanada
| | - Quinn Daviduck
- University of AlbertaDepartment of SurgeryEdmontonCanada
| | | | - Xinzhe Shi
- Royal Alexandra HospitalCenter for the Advancement of Minimally Invasive Surgery, Department of SurgeryEdmontonABCanadaT5H 3V9
| | - Rachel G Khadaroo
- University of AlbertaDepartment of Surgery, Divisions of General Surgery and Critical Care Medicine2D3.79 WMC, University of Alberta Hospital, 8440‐112th Street NWEdmontonABCanadaT6G 2B7
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McIsaac DI, Jen T, Mookerji N, Patel A, Lalu MM. Interventions to improve the outcomes of frail people having surgery: A systematic review. PLoS One 2017; 12:e0190071. [PMID: 29287123 PMCID: PMC5747432 DOI: 10.1371/journal.pone.0190071] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 12/07/2017] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Frailty is an important prognostic factor for adverse outcomes and increased resource use in the growing population of older surgical patients. We identified and appraised studies that tested interventions in populations of frail surgical patients to improve perioperative outcomes. METHODS We systematically searched Cochrane, CINAHL, EMBASE and Medline to identify studies that tested interventions in populations of frail patients having surgery. All phases of study selection, data extraction, and risk of bias assessment were done in duplicate. Results were synthesized qualitatively per a prespecified protocol (CRD42016039909). RESULTS We identified 2 593 titles; 11 were included for final analysis, representing 1 668 participants in orthopedic, general, cardiac, and mixed surgical populations. Only one study was multicenter and risk of bias was moderate to high in all studies. Interventions were applied pre- and postoperatively, and included exercise therapy (n = 4), multicomponent geriatric care protocols (n = 5), and blood transfusion triggers (n = 1); no specific surgical techniques were compared. Exercise therapy, applied pre-, or post-operatively, was associated with significant improvements in functional outcomes and improved quality of life. Multicomponent protocols suffered from poor compliance and difficulties in implementation. Transfusion triggers had no significant impact on mortality or other outcomes. CONCLUSIONS Despite a growing literature that demonstrates strong independent associations between frailty and adverse outcomes, few interventions have been tested to improve the outcomes of frail surgical patients, and most available studies are at substantial risk of bias. Multicenter, low risk of bias, studies of perioperative exercise are needed, while substantial efforts are required to develop and test other interventions to improve the outcomes of frail people having surgery.
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Affiliation(s)
- Daniel I. McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tim Jen
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nikhile Mookerji
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Abhilasha Patel
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manoj M. Lalu
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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A Systematic Review and Meta-analysis Examining the Impact of Incident Postoperative Delirium on Mortality. Anesthesiology 2017; 127:78-88. [DOI: 10.1097/aln.0000000000001660] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
Background
Delirium is an acute and reversible geriatric syndrome that represents a decompensation of cerebral function. Delirium is associated with adverse postoperative outcomes, but controversy exists regarding whether delirium is an independent predictor of mortality. Thus, we assessed the association between incident postoperative delirium and mortality in adult noncardiac surgery patients.
Methods
A systematic search was conducted using Cochrane, MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature, and Embase. Screening and data extraction were conducted by two independent reviewers. Pooled-effect estimates calculated with a random-effects model were expressed as odds ratios with 95% CIs. Risk of bias was assessed using the Cochrane Risk of Bias Tool for Non-Randomized Studies.
Results
A total of 34 of 4,968 screened citations met inclusion criteria. Risk of bias ranged from moderate to critical. Pooled analysis of unadjusted event rates (5,545 patients) suggested that delirium was associated with a four-fold increase in the odds of death (odds ratio = 4.12 [95% CI, 3.29 to 5.17]; I2 = 24.9%). A formal pooled analysis of adjusted outcomes was not possible due to heterogeneity of effect measures reported. However, in studies that controlled for prespecified confounders, none found a statistically significant association between incident postoperative delirium and mortality (two studies in hip fractures; n = 729) after an average follow-up of 21 months. Overall, as study risk of bias decreased, the association between delirium and mortality decreased.
Conclusions
Few high-quality studies are available to estimate the impact of incident postoperative delirium on mortality. Studies that controlled for prespecified confounders did not demonstrate significant independent associations of delirium with mortality.
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